CAPT. Chad Garrett  0:06  
All right, so my name is Chad Garrett, and let's get this show started. Mr. Smith, you've got the floor.

Christopher Smith, NPA  0:24  
Really helps if you unmute. Hello everybody. Hello and welcome to the National Institute of Corrections clinical pearls webinar series. My name is Christopher Smith, and I'm a national programs advisor with the National Institute of Corrections. We are thrilled to have you join us for this info, more informative, nine part series exploring the integration of clinical pharmacists into primary care and highlighting proven approaches for correctional team medicine. Before we begin today's session, I'd like to cover a few important housekeeping items. Each webinar in this series is scheduled to last approximately one hour. The sessions will be recorded and once captioned and made 508-compliant will be available on the NIC website. This is a listen-only event, meaning participant microphones are muted. However, we strongly encourage, strong encourage engagement through the WebEx chat function. Please use the chat to share your thoughts, ask questions or request technical support. We will address as many questions as possible during the Q and A portion at the end of the webinar to practice the chat function. If everybody could please type into their chat whether they prefer gardening or cooking more. So if you go ahead and put your thought into your chat comment. I'd appreciate it. You guys have a moment. 

We got quite a few answers. It looks like it's pretty well split. That's great, guys. Thank you. So if you experience any audio difficulties, we recommend connecting to the webinar audio via telephone using the phone number provided in your registration confirmation email throughout this series, we want to hear from you. You can always email Health Programs Manager, Chad Garrett at cagarrett@bop.gov with any comments, concerns or ideas for the future events, I and my team here at NIC, including some great staff from the NIC library, will be posting information in the chat during this presentation. Again, if you have any questions, please type them into the chat, and we will answer as many as we can at the end of the webinar. Thank you again for joining our webinar, and now I give you the Captain, Chad Garrett.

Speaker 1  2:49  
Thank you so very much. So welcome everybody. Today, we're diving into a topic that is both clinically compelling and critically important, how clinical pharmacists are shaping the future of Correctional Health Care. Now, know what you're thinking, pharmacists just count pills, right? Well, if that were true, we could replace them with vending machines. But in reality, clinical pharmacists are much more than medication dispensers. They're frontline providers, disease state specialists, key members and managing chronic conditions and infectious diseases and even managing opioid use disorder, they are the unsung heroes behind the wall ensuring that patient centered care isn't just a concept, but a reality.

Speaker 1  3:43  
So...let me introduce you to your speakers today. First, Lieutenant Commander Brorby began his BOP career in March 2020, following seven years as an acute care clinical pharmacist in a community hospital. He has served at FCI Greenville, FCC Tucson, and is currently the Chief Pharmacist at FCC Florence, the supermax. His primary clinical interests and areas of expertise, including anti-microbial stewardship and hepatitis C. In his free time here in Colorado, he enjoys exploring the blue skies and mountain highs of sunny Colorado with his wife and three children. Commander Klang has been detailed to the Federal Bureau of Prisons for over 15 years, advancing through staff and chief pharmacist roles to her current position as a regional Chief Pharmacist. Her main collateral duty is the National Program Coordinator for the Hepatitis Clinical Pharmacy Consultant Program. That's a mouthful. She's been doing that since 2017, she was formally a regional consultant within the program since its inception in 2011. This program ensures clinically appropriate and fiscally responsible selections of hepatitis B and C treatment regimens via the non-formulary request process from all federal bureau prison sites and serving as the subject matter expert in the field. So what can you expect today, well, from optimizing treatment strategies for chronic and infectious diseases to leading transformative pharmacy programs. These two will amaze you with the programs and knowledge, no pressure now, my friends that they will provide you and with that, the floor is yours. Do you want to take over sharing?

Commander Katrina Klang  5:40  
Okay, can you still hear me? Just making sure? Thank you all right, so thank you for that introduction. Today we're going to be presenting on hepatitis C, cascade of care in corrections, also a mouthful and well, Chad already introduced, but I do want to say I treated over 800 patients for hep C in my local clinic at FCC Florence, Colorado, supermax, same as Alex, for nine years, unfortunately, have not been able to continue direct patient care in the last few, and I finally like to joke that making grown men cry because they've been cured has been the highlight of my career. Alex?

Lieutenant Commander Alex Brorby  6:37  
Hello, I am Lieutenant Commander Alex Brorby, I apologize. I had to interrupt my sharing so I could get my camera on here. Nothing like the real production day. As Captain Garrett mentioned, I am currently the chief pharmacist at FCC Lawrence and I have introduced pharmacist driven hepatitis C treatment at both FCI Greenville and FCC Florence. Once Katrina moved on up to greener pastures, I took over her clinic here at FCC Florence, and I have been involved as a regional consultant for a couple years now, approving and reviewing several 100 non-formulary requests across the BOP so with that, we will move on into our presentation here. These opinions are my own and Katrina's. They do not represent the BOP or the DOJ and our objectives here, as we go through our material, we want to identify national and global hepatitis C elimination goals and describe how these can be applied to the correctional environment, we'll incorporate the cascade of care model to optimize local screening and treatment practices, and hopefully, by the end of our material here, you and the audience will be able to formulate a hepatitis C treatment process which addresses correction specific concerns for successful elimination. So right off the bat, we just kind of kind of want to test the waters and see what our audience looks like. Because if there's one thing we know about the correctional environment, it's just nothing is uniform. Pretrial situations, sentenced inmates, state prison, federal prison, everything's different. The big message we're driving home with this material is, no matter what your specific circumstances, we just want to share some information that may help whatever resources you have in optimizing your treatment approach and really working towards hepatitis elimination. So it looks like we have our poll opened, and we're waiting for some results here, and they're trickling in. 

Speaker 1  8:42  
I'll give you about another 10 seconds. 

Speaker 2  8:56  
All right, looks like we do have over half of our audience here has answered so far, which is thrilling. It looks like we're at let's see 17 federal, 13, state, three county and three other so... very exciting. It's a pretty good mix. So hopefully we'll be able to share some knowledge and have a productive meeting today, and with that, I will turn it over to Commander Clang to talk about hepatitis elimination.

Commander Katrina Klang  9:30  
Thanks. Okay, so let's talk about elimination of hep C. Why do we care? And what is the context? You may have also heard this referred to as micro elimination. I just like simplifying things, and what this means is elimination or eradication of hep C at any level. This could be your local clinic, your community, your institution, your agency, the whole country, the whole world. And that's kind of the point of what we're talking about today. Next slide, please. And in this respect, we, unfortunately, we're not Unicorns. We are part of a bigger movement. So the viral hepatitis national plan is a federal agency collaboration. So we have BOP, IHS, CDC, alphabet soup, you name it. It's probably there. We gather metrics and create plans and interventions to be widespread in our approach. And even though it's federal, you know, lots of agencies have their, you know, fingers in a lot of different areas, and so it does trickle down to like the state and the county level too. Operation Cancer Moonshot is was a President Biden initiative to prevent cancer deaths. We know Hep C can progress to cirrhosis and some, unfortunately, to hepatocellular carcinoma. So hep C elimination is part of this. And the World Health Organization has a goal to reduce new hepatitis infections by 90% very ambitious, and death by 65% by the year 2030, which we still have some time, but time to take in. And if you ever feel like a cog in a machine, just know you are an important cog, and we do see you next slide, please. So let's do a quick review of hep C infection. In case anyone wandered in here by accident. It's a single strand RNA virus. It has six genotypes with various subtypes. Transmission is primarily via blood, and many of these listed here are more common in our patient population, as I'm sure we're aware. So when we talk about high risk behaviors, we're referring to things like sharing needles with injectable drugs or tattoos. Transmission by fighting is less common, but it still happens same thing with sexual intercourse. Next slide. So if there's one thing to take away from today, it's that hep C is curable. Hopefully we all know that by now, because it's been about a decade, if I may make a gentle jab, it's not like diabetes clinic re-follow that patient for months to years. You can hep C, you can treat them, and hopefully that you never see them again for hep C, because they'll be cured and not reinfect, ideally. So the majority of patient cases can be treated without specialist intervention. So save your medical trips. And I could talk about hep C all day, literally, but please note that cirrhosis, hepatitis B co-infection and hep C treatment failure are beyond the scope of this presentation. Next slide. So to continue our review, this slide demonstrates why it matters to eliminate Hep C. So our patient engages in a high risk behavior. They're acutely infected with hep C, and a lucky 25 to 30% will spontaneously clear on their own without treatment, which I love, and the rest progressed to chronic hep C infection. And the percentages are here. But the point is, we have some patients who develop cirrhosis, compensated or decompensated, some who develop hepatocellular carcinoma, and some who can die from any of these so depending on your practice setting, you may see these patients for only a few days, a few months or years, but at every point in time, we can still make a difference in their lives by disrupting this progression somewhere. So what we do? How we do it matters, next slide. And then to conclude this brief overview of hep C listed here are the FDA approved treatment regimens we use the most in the VOP. These are for when the patient has no prior DAA or direct acting antiviral experience, and either no cirrhosis or compensated cirrhosis at most. We will be using brand names, just for simplicity. Also, I'm kind of lazy. The rest of the presentation, you can see treatment durations are eight to 12 weeks. I'm sure many of you out there probably remember six to 12 months of interferon, with or without ribovirin, and let's not even discuss the short lived protease inhibitors in 2011 2013 time period. So it's much simpler. So the takeaway from this review is we've identified the problem. It's a curable disease. It matters to our patients that we cure them and we have safe and effective treatments. Next slide. Now let's look at how hep C elimination is related to our unique and it is unique practice setting. Many of you may have heard of the iron law of imprisonment, though over 90% of those incarcerated will return to the community. So what we do inside absolutely matters on the outside, our patients go back to their families, their communities, which are our communities too. So Correctional Health is public health, and the health care that we provide is everyone's health care. And next slide.

Speaker 3  14:35  
And lastly for elimination, elimination efforts, some of you may have heard the term syndemic, which is written out there. I'm not going to read it. It's just a fancy way to say that we can also try to treat the underlying or associated reasons that some of our patients infect and probably will reinfect with hep C, such as Opioid Use Disorder. We hope you appreciate this comic where this lucky guy is curious Hep C and. Reinfects, and is right back where he started. So this is mostly for awareness that while Hep C is relatively easy to treat, we still want a more comprehensive approach to treating our patients and see please stay tuned for our sixth presentation in this series on opioid use disorder.

Lieutenant Commander Alex Brorby  15:21  
All right with that, we are going to jump into the cascade of care. So we kind of have the 30,000 foot view of why hepatitis C treatment is important. So now we're going to kind of drill down and look at the actual nuts and bolts of what that looks like in our institutions and our facilities, so primarily screening and treatment. So as we look at our cascade of care, we kind of have a sequence of events here. This starts with screening, identifying the problem. Once you've identified the problem, getting that patient in front of a provider who can facilitate treatment and cure, and then last but not least, the appropriate follow up. So this image here just kind of highlights why it's important to have a systematic and effective plan for hepatitis C care. You know, if we look at this pool here, we imagine this is all the people who have hepatitis C, just on a national level. If we look at how many actually are diagnosed and aware, it's kind of a troubling figure. So I mean, if we're only identifying one out of every two cases of hepatitis C in the world. How can we possibly effectively eliminate it's kind of a good news. Bad news situation in the correctional system, you know, the bad news our patient population has a disproportionate rate of hepatitis C. The good news is that, since we are in such a structured and controlled environment, to lack of a better word, we have a captive audience. We have a little bit more control in instituting processes. They can be much more effective than that 50% rate in screening our patient population. So as we kind of progress through the cascade of care, really, once you've identified the problem, it's a little bit less grim. So you know, half of the people who have been screened and identified go on to have that confirmatory test. So it's important to kind of distinguish that antibody screening versus confirmatory testing. You know, what does a hepatitis C antibody tell us? It tells us that at some point in the past, this patient has been exposed to hepatitis C. It doesn't necessarily mean that there's an active infection that requires treatment. So Katrina mentioned that 25 to 30% of acute hepatitis C cases resolve with no ongoing chronic infection. So that person will still always test positive on an antibody screen, which is why that confirmatory test is so important. What if we successfully treat someone? There's no virus anymore, but that antibody screen will always be positive. I'm going to talk a little bit about how important education is in the patient provider relationship. But as hepatitis C providers and advocates, it's also important that we educate our providers. There have been multiple instances where I've just in reviewing a chart, seeing someone have a positive hepatitis C antibody, and then someone reviews the lab and says, Okay, we'll add a hepatitis C diagnosis and go from there. It's really not the way it's supposed to work. You know, you really need that confirmatory viral load test to confirm that there is actually an infection that we need to be treating. So we have our confirmation. This is our linkage to care. You know, about one out of every five gets linked to care once you get in front of a provider, pretty good amount actually undergo treatment, and then we lose a little bit in our follow up. So again, that's why it's important to have an effective and systematic plan so we can get these numbers up and effectively eliminate hepatitis. Get rid of my laser pointer there. Okay, so the first thing we'll talk about is screening. So the gold standard really is universal, opt out antibody screening. Happy to say that effective April 1, the BOP will be implementing a standard to support the early detection and treatment of HIV and hepatitis C. So it will require the ordering of HIV and hepatitis C lab tests for all newly committed inmates, as well as those who have been out of custody for more than 30 days. So just screen everybody. As I mentioned, we kind of have a disproportionate patient population, we should just be offering these tests to everybody. As I mentioned, it's important to get that follow up, confirmatory viral load, and it is prudent to think about, in your specific treatment situation, where is the most effective place for you to implement your screening? As I mentioned, we're pursuing that screening at intake, that's the first time they see any sort of healthcare provider. It could be a nurse or a paramedic or an EMT in your situation, it could be an HMP, where they're first seeing that either a mid level provider or a physician. So we're gonna have our first poll question here. Does your practice setting? Offer routine opt out hepatitis C screening. And this could be in contrast to just, you know, maybe it's just per patient request, maybe your system identifies high risk factors, or could be in other so whether or not there's an actual poll question, maybe just throw it in the chat. Yes, no other I

CAPT. Chad Garrett  20:26  
was gonna say, we need to throw it in the chat. Okay,

Lieutenant Commander Alex Brorby  20:31  
so far, the overwhelming majority that I'm seeing are yeses, which is exciting. Cool. All right, excellent. So check mark, screening is all good. We're ready to move on. So after we have screening, we've identified the condition that needs to be treated. Our next step is linked to care, so we need to get this patient in front of a provider, and this is just the question of what your resources are, what your workflow is, what your patient population is. To determine how you're going to get from screening to treatment, there needs to be some sort of process to schedule an evaluation with a provider. Here's where I'll do my shameless professional plug as a pharmacist in corrections who's worked at multiple institutions. I will say, if your pharmacists aren't involved in hepatitis C treatment, in your elimination efforts, I would urge you to kind of ask the question, why not? I would ask you to consider getting involved, saying, Hey, we're really trying to pursue this. Would you be interested in helping out any way you can? I've worked in a lot of practice settings throughout all over the country. One of the constants throughout all that is I've encountered pharmacists who were almost always willing to kind of expand their window practice at the top of their license, do what they can do to help increase patient care. So professional plug. Get your pharmacist involved. We have institutions in the BOP where infectious disease nurses play a big role in terms of scheduling with providers, ordering labs, kind of starting that non formulary prior authorization review process. We all have different resources. We all have different challenges. So just try and take a look at what you have at hand and what would be the best way to implement those tools in terms of getting your effective process goes it is really important to have a diagnosis added to the patient chart. It helps, helps you organize your data, as we know, our patients move around a lot. So it also helps continuity of care in terms of, you know, maybe we got through the screening. We couldn't get to the link to care before they go out on a red or a detainer, but hey, we promptly got that diagnosis added to the patient chart, so when they go to their next correctional environment, they're able to get effective, timely treatment. Data Analytics is important. I'm going to talk a little bit about the BOP dashboard, which is more or less just how we can organize data that gets automatically pulled from our EMR, which basically just automatically creates a spreadsheet. So even if you don't have something that does it on your own, it's always something that could be done tediously and manually by hand. But the next slide, we'll kind of talk about how a tool like that can be used to help aid your elimination efforts. So there's a lot going on here in this image, I'm going to try and orient you, and we'll kind of walk through and see how we use this tool. So this is just a screenshot of what our dashboard looks like, and it tells us a lot of things all at once. So each line of these, each row is a different patient, and it tells us what sort of HCV status they have, whether or not they've been treated before, whether they're pending an evaluation, whether they have treatment in the future. It'll tell us what genotype we have on record. It'll look at their Apri, which is the AST platelet ratio index, basically just tells us that there might be some liver damage ongoing. They'll tell us their screening results. There are viral load results and date, if they have another lab scheduled, do they have a release date scheduled, and are they going to an RRC or a halfway house? All of these little tidbits of information can be useful in organizing your correctional treatment program. So it gives you the tools to basically get a plan together, like, say, your plan is you want to organize by those most at risk of morbidity and mortality, so you can sort by your Apri. The higher it is, the worse. So maybe you're going to tackle those with the highest apris to minimize morbidity and mortality. You can look at your release date. You're going to swear that no one's going to walk out your door with hepatitis. So you're going to go from getting out soonest to latest and make sure that's who you're prioritizing. It's not pictured in this image, but we also have the opportunity. To filter by housing unit or institution. So there's some merit in having a housing unit based treatment approach. So say you want to go unit by unit, you're reducing the reservoirs of infection. You know, hepatitis isn't being passed around there in that housing unit. I will also say, sometimes I'll have 5678, patients on a schedule for the day, and I go and everybody's locked down, so it's almost a wash unless I want to go housing unit by housing unit to see people at the cell front. Well, if I schedule people by housing unit, I know I only have one stop to make. I can knock them out pretty quick, and I can still be productive that day. You

all right? So you have your patient, he or she has hepatitis, you've linked them to care. They're in front of a provider. What does, what does kind of an ideal treatment encounter look like? So we'll kind of just have a couple pearls here before we get to follow up. So your first step there is just to get that initial offer. It's kind of important to remember that a lot of these patients this you could be their first real sit down encounter with a healthcare provider. Maybe they were told they had hepatitis five years ago, but no one really talked to them and told them what that means, what the risks involved are, what the treatment options are. Maybe they have concerns. As we talked about earlier, hepatitis C treatment, 10 to 15 years ago, wasn't that great? You were on shots for a long time that were bad side effects, the treatment outcomes weren't that great. Maybe they had a buddy who said, No, I had hepatitis. I was treated 10 years ago. It was terrible, and I didn't even get cured, and no one's told them about the medication we have options for today. So the big goal here is just education, education, education, the more you can make your patient a stakeholder in their result, the more likely they will be adherent to treatment. Maybe the more likely they'll be able to kind of abstain from those high risk behaviors. Just bring them on so they're part of the treatment team, it's important to have a thorough review of their treatment history and their high risk behaviors. So these are the kind of background questions that you're looking at. Did you know you have hepatitis? Have you ever received treatment for hepatitis? There's some questions here that kind of have the deep dive of questions you might ask the patient. But again, just you know, the biggest distinguishing factor, almost, in which treatment you're going to provide your patient is, is this treatment naive or not? So whatever results they can provide you, the better. It is, kind of something to be aware of, that the more available the direct acting antivirals are, the more we offer this treatment, the higher the likelihood that you're going to come across patients who have been treated before. So it's important to have that kind of process in place. To get a thorough history, as we talked about, this is a great time to start addressing opioid use disorder. Sure different correctional environments are at different points in terms of having the resources available to provide treatment for opioid use disorder. I know the BOP has come a long way in the last few years, so it's a really good tool to have in order to make sure that not only are you curing your patient of hepatitis, but you're kind of addressing the root cause of how the hepatitis came about in the first place. This is a great time to look at the patient holistically and talk about vaccinations. So some of the kind of baseline labs that we need in order to get someone ready for hepatitis C treatment is Serologies for hepatitis b1. Of the best counseling points I have with my patients is saying, you know, one of the big differences between Hepatitis C is Hepatitis B, is that we have vaccinations for hepatitis B. A lot of the things you do to get hepatitis C can also result in getting hepatitis B. You've been lucky so far. You don't currently have hepatitis B, but you're also susceptible. Would you be interested in getting vaccinated while we're going through this process? The vast majority of patients I talked to about this are all on board. I mean, they're they're in the process of, kind of working towards better health, kind of releasing as a better person than they were before. A lot of them want to get out on the right foot. So just make sure that you're having a holistic encounter and treating the patient as a as an individual. It might be important to obtain medical records. You know, especially as I mentioned, more and more and more patients are having prior treatments. I know, the first time I had an encounter with a patient who was like, Yeah, you know, I was treated a couple years ago. I don't, I don't remember what it was or how long I took it. It was at this facility. I was like, Oh, well, we're going to have to get your records. And then it dawned on me, like, I have no idea how to get your records. So it's almost a certainty that your facility or practice setting has a process for this. It's just important to be familiar with it, so when it comes up, you're not on your back foot like I was at this point. I do know how to request medical records, so I can learn here, as we talk about the correction setting, there are specific custody we're. Related factors that we need to be aware of. Duration of sentence is a big one, or upcoming transfer or release. You know, one of the biggest things we don't want to do is start a patient on treatment, have them leave halfway through, not have the continuity of care established and fail treatment. Sometimes the inmates will be cognizant of this in terms of transferring. I know here at Florence, sometimes there have been inmates who are like, No, I'm I'm pending a really transfer to another institution for a specific program. I don't want to be on a medical hold, because that's what we do when someone's on treatment, because we really don't want them to have an interruption, and that's okay. They're, you know, they have autonomy. They can be in charge of their care, but I do try to facilitate still getting treatment. So I'll still go through the approval process. I'll say, Yes, we're going to get you approved for this medication. When you get to your new facility, advocate for yourself. Just write it intake. Say, Hey, I have hepatitis C. I was going through the treatment process. The provider got me all approved. Can you please facilitate my treatment. It should be pretty easy, and there's been pretty good results with that. Another tool we have is looking at disciplinary records. So if you're doing your high risk review with your patient, and he says, No, I haven't done any of that for years, and you can look at his disciplinary record and he got a tattoo six months ago, opens the doorway for that frank conversation where you can say this is important and why, so you can have an open and honest dialog. Always good to look at drug interactions. Big discussion point is medication adherence. One of the biggest counseling points I say, is, you know, we have these great medications, very high cure rates, but they only work if you take them as you're supposed to. If you start skipping doses here and there, your treatment could fail, and it could be a lot harder to get you treated again if you have that treatment failure in your history. So please, if you're having issues with adverse effects or you know you need your pill line time change because of a work assignment, please just reach out to me. Don't stop taking that medication. Good thing to cover. And once you've done all those steps you've dotted all your I's and crossed all your T's, as we mentioned earlier, our goal here is to select the most appropriate regimen from a clinical and fiscal perspective. But we're not quite finished yet. We want to finish strong. We want to tie up the loose ends. We want to have good and adequate follow up. We need to make sure we talk about our 12 week viral load testing. So 12 weeks after we finish treatment, we need to get that viral load done. Just to make sure they've cleared the virus, we need to talk about the risk of reinfection. One of the biggest counseling points I also talk about is that, you know, it's great that hepatitis C can be cured pretty easily with these awesome drugs, but you're cured and not immune. So whatever you did to get hepatitis C in the first place, you can always get it again. It is also important to have an open door approach. So, you know, you've, you've kind of hammered home how important it is to avoid these behaviors. You've talked about these great medications they're going to get on, and how important it is maybe six months down the road, they're cured and they start, you know, they get another tattoo. Do they feel like they can come to you and talk to you and say, Hey, I know we had all the stock. I know we discussed it, and I said I wasn't going to do anything, but I messed up. Can I get screening? It is important for our elimination efforts to have that open door approach. It's not, you know, disqualifying them from further treatment, make sure that we have good communication and a two way street. That's going to bring us to our first patient case. So kW, he's a 32 year old male, and he comes to your clinic. He has hepatitis C. His genotype is one A, and he has a pretty extensive history of opioid use disorder with multiple prior hepatitis C treatments. He was treated with confirmed SVR in 2019 2021, 2022, all with different genotypes. It's important to note that we talk about treatment naive that's for a specific virus. So if you are successfully cured, and you are reinfected, and it's a brand new infection. You're not technically treatment naive. So these were all treated as new infections. And he does also report ongoing IV drug use with shared needles. So KW is basically our cartoon character from earlier. He was free, he fell right back in the stocks. So what are you going to do? Are you going to a provide counseling on importance of re avoiding reinfecting behavior and offer hepatitis C treatment, provide your counseling and maybe follow up in six months to see if you can avoid high risk behavior and then receive treatment. Are you going to do your counseling offer medication for opioid use disorder in addition to hepatitis C treatment. Or do you wash your hands of kW? He's had his chance. He's blown it for the last time, and we will wait a little bit of time so those ball answers can start trickling in. You. Uh, by full answers, I also mean, feel free to type them in the chat, as many people are doing.

All right, so we have kind of an overwhelming flood of seas. Commander Linton says, Call for me, we'll see about that. Okay, so everyone basically said C. I think we would all agree, in a perfect world, C is the good answer. We want to treat the patient holistically. We want to address the root cause, and we want to provide an opportunity for kW to go on through life without hepatitis C, I will say, we don't always live in a perfect world. What if your facility doesn't have the opportunity to offer medication for opioid use disorder? I know there are certain situations where I've had patients who have ongoing high risk behavior, but they are really motivated to get treatment, and it wasn't a situation where my facility could support medications for opioid use disorder at that time. So we did follow up in six months, and it can be, you know, a recurring appointment, check back every three to six months. Another thing to consider is timing of release. You know, maybe they do have this opioid use disorder. They're using IV drugs regularly, but maybe the biggest issue they have is they don't have access to clean needles in prison. Maybe you want to wait till they get close to release. You know, kind of that three to six month window to release, and they're confident they can walk out of here free of hepatitis C, and they'll be able to avoid sharing needles on the streets. It all depends on what your resources are. What is best for the patient in front of you? Very happy that no one answered D and it's not the ideal answer. We want to do what we can for our patients. So now we're going to look at kind of tools at hands. Tools at hand, things you can take stock of resources you have to help get your program in place to really make progress towards elimination. So some things that everyone has access to is AASLD guidance. So that's the American Association for the Study of liver disease. These are the guidelines that our bop hepatitis C clinical guidance documents are based on. They're available online. Many of the situations that we kind of discussed as being outside the scope of this presentation. So cirrhosis, hepatitis B, co infection, treatment, failure, things like that. There is a specific and helpful section for almost everything you could possibly want with these guidance. Take some time just read through it. Very interesting stuff. Hopefully you have access to something like up to date or some other clinical references. It is great if you can have a Hep C hero at your facility, someone who's passionate, committed, who can kind of have some accountability and take charge of your efforts. We'll talk a little bit more about the BOP Clinical Pharmacy consultants in the in a short while, but it's helpful to have some resources of people who are willing to take on extra training, who can serve as subject matter experts, kind of ready to answer the phone when people have questions. Warm line and the extension for community health care outcomes or echo project are somewhat similar. So the warm line is through the University of California, San Francisco. These are situations where you can kind of present complicated patients to experts, and they will weigh in and give you advice. So here in the BOP we have kind of a quarterly warm line opportunity where if we have one or two or three cases that we're just kind of scratching our heads at, or we just want a little bit of a double check. We have a little case presentation session with them. We get a lot of good information from them. So lots of resources out there. You just need to see what you need for your particular practice setting to get you going. Next few slides are just a little bit of snippets from those guidelines. So one of the biggest questions I get as a consultant is, you know, my patient missed X number of doses. What do I do? Do I start over? Do we just keep going? This is an example of just like a really helpful infographic from those guidelines that very clearly spells out what you need to do in this particular situation. Again, this is a snippet from the examples of what kind of unique and key populations with hepatitis C infection that are available so almost anything you can imagine, renal impairment, kidney transplant, pregnancy, children, any sort of complicated thing that comes across your door. If you can't get someone out to a specialist or a consultant, you do have resources to see. You know, what do I do in these situations? We're moving on to our next poll question here, just kind of a yes or no. Does your facility utilize pharmacists in a clinical capacity to provide hepatitis C treatment? And while we're waiting for answers to come through, I would just say, if not, why not? You know, what barriers do you have to implementing pharmacists? Maybe you don't have pharmacists. That could be the case. We're lucky in a federal system where we're not kind of bound by state laws that may restrict pharmacists clinical practice according to a state pharmacy board. So I know a lot of those rules are changing after COVID, and it was kind of an all hands on deck approach, and a lot of that red tape fell by the wayside. So hopefully after this presentation, if you're not utilizing pharmacists for hepatitis C treatment, you might consider you know seeing what you could do to implement that process.

CAPT. Chad Garrett  40:32  
57% to answer. So I'm going to give them 15 more seconds.

Lieutenant Commander Alex Brorby  40:37  
Very generous of you. Captain Garrett, I'm always very generous.

CAPT. Chad Garrett  40:48  
All right, so we have about 15

Lieutenant Commander Alex Brorby  40:49  
yeses six, noes three, not sure. So seems like there is an opportunity there for some more robust integration of pharmacists into this treatment model. I will say, if you do have any questions or recommendations or you'd like to talk about clinical pharmacy from hepatitis feel free to reach out to myself or commander clang. It's something we're happy to talk about. And with that, I will pass it on back to Commander clang for the correctional lens. And you are muted. Ma'am.

Commander Katrina Klang  41:24  
Thank you. I double clicked. We've had an excellent review of the screening treatment processes. It seems pretty clear and straightforward, right? So how does the correctional lens, the correctional aspects of our workplace environment, affect these processes? And the answer is yes. Next slide, we have a laundry list of things to consider behind bars patient movement includes duration of stay, transfers within or out of the agency, releases. Ritz, like Alex had mentioned before, and as he said, we do our guidance requires a medical hold because we don't want to interrupt treatment. We've had, unfortunately, plenty of situations where patients transfer on treatment. Sometimes no medical hold was ever done. Maybe they removed it midstream. Sometimes, because there's a more urgent custody reason, which I would never stand in the way of a custody reason to transfer, just try to coordinate efforts and make sure they continue treatment. You know, get a seven day supply kind of thing. And then there's just those sudden releases or writs that are outside of our control. So as much as I want to treat everyone, I highly emphasize doing the right thing for the patient, not putting them at risk for treatment interruption, potentially treatment failure or development of virologic resistance. As much as I love Hep C, I hate seeing the RE treatment request, because I really got to make sure we we ticked all the boxes and recommend the right regimen. And I would just rather not have to be in that situation. So if there's a possibility of releasing on treatment, ensure they understand to continue and complete it and get their follow up viral to see if they're cured. That's the whole point. And ensure that you know if you can anticipate the release, that they get their release meds with the remaining day supply, and that you have a good process for when they leave to have their medications in hand, what they do, and then after that, I hope they make good choice, directly observed treatment, D O T is otherwise known as pill line. So in V, O P, all of our Hep C treatment is to line due to cost and the ability to monitor compliance. So if your site does use D, o, t, how many treatments can you start at once? Particularly from a staffing level, because we don't have hep C treatment vending machines. So some of our sites have spaced out treatment starts. They'll block them like five at a time, the first Wednesday of each month. Some of them, and I'm totally guilty as charged, will dump 20 treatments at once and get yelled at. So just consider what fits best in your operations, or for drug cost and procurement, everyone's favorite topic, other than opioid use disorder, is money. I'm sure we all operate on budgets we wish were bigger. So back when the DAS came out in 2014 they were just so expensive. I had sites that tell me the cost of a few treatment rounds would like bankrupt their annual medical budget. So we moved to a centralized funding and fill model years ago, which has worked very well. So all funds are set aside in central office. Our central office and local sites don't have to think about it. So for your site, you know, are your is your funding local or centralized? And I wish we didn't have to think about money, because we did not go to school for this, but it is something to consider. What could be changed to help improve your financial access to medication contracts, temporary price reductions with manufacturers, the Louisiana Department of Corrections, Netflix models very similar to ours, lots of options out there to explore and then ensuring correct treatment, not specifically correctional. But we, as Alex said, we do have a captive population, so our medications are non formulary or like prior auth in the community. It's really more of a clinical review process, because we do treat everyone. So. And we'll talk about the clinical pharmacy Consultant Program in a few more slides.

Unknown Speaker  45:05  
Next slide.

Commander Katrina Klang  45:08  
As we know too well, we have areas with limited access, so your special housing unit or shoe or the whole lockdown units, and sometimes it's hard to get those escorts to bring them to medical or even to bring them to the treatment room inside the unit. I'm sure many of us have done clinic down range in the units, either pulling them out if you can, or talking through a cell door and smelling the inside of their cell, which is always fun, but try not to let limited access be a barrier to treating your patients. And while non adherence is certainly not unique to the carceral setting, we can tell when they're non adherent, because we use the electronic medication administration record for the DoD or pill line, and you can have a more timely intervention. Like, Hi, what are you doing? Please show up for your treatment. That kind of thing. At Florence, we had a set we have a centralized pharmacy, so sometimes I would communicate with the staff doing pill lines to be like, Hey, can you go check on patient so and so, and reminds him to keep taking his treatment for reinfections. Like I said, we've seen a noticeable increase in reinfection treatment, which I guess is not unexpected. That's a good sign. It means we're treating but it also highlights what I mentioned before about treating our patients comprehensively. So are there patients with OED that we could be mitigating some of their high risk behavior by linking them to care and documentation? I'm sure we all know if you didn't document it, it didn't happen. So with our population, we strongly recommend you document your counseling discussions about prior treatment cirrhosis status. This greatly helps when it comes to those retreatment situations, and needless to say, we have a litigious minded population. So let's jump next slide to our second patient case. So we have a 24 year old male, has Hep C wants treatment, but has a halfway house in six weeks. What is your treatment approach? A is to start as soon as soon as possible send the remainder. B is to delay until he goes and send the full course. C is to advise him about the risks are too great, and to get treatment when you get out. And D is you got to weigh your halfway house before we will treat you.

CAPT. Chad Garrett  47:20  
The poll is open,

Commander Katrina Klang  47:22  
yeah, you can keep it pretty quick, because hopefully this is an easy one to answer.

CAPT. Chad Garrett  47:37  
Now we're getting some answers rolling in. Okay? We'll give them 12 more seconds. You

Commander Katrina Klang  48:04  
What do we have? For some reason, polls are not showing up on my screen. The overwhelming

Lieutenant Commander Alex Brorby  48:07  
response is a, and then we have one of each, B, C and D.

Commander Katrina Klang  48:13  
Oh, great. So let's just go through the other options. So I agree with choice A, that's what we do. So option B. So between option A and option B, the only difference is that you start him now, or you or you give him all of it when he leaves. As a pharmacist, I'm super leery about sending a whole course of treatment that they've never started before when they leave, because I don't know. Do they have questions? Do they have side effects, you know, things like that. So I'd rather get as many doses in as possible right now and then send the rest with them for option C, there are a few who do choose this route and let it be their choice, because maybe they don't want to be treated in prison, either they don't like us, or there are temptations within the wall that they will not be susceptible to on the outside, so they'd rather wait until they're out, or they just prefer treatment in the free world. Who knows? Choice D I'm not sure who would choose to stay in prison any longer than they had to. This has not been a popular choice in the past, when this was an option. I don't know of anyone who's actually done it, so I think there's an addendum to this slide, right, right? So consider how your answer might change. There's no poll for this one, just something to think about. If he was releasing at the end of his term, rather than going to halfway house, it's pretty much the same. The difference is that halfway house, we know they're going to have medical continuity of care, so I feel much more comfortable sending them with the remainder, if they're doing a full term release, find out what their situation is after release. Most patients that I you know anecdotally from my clinic, have a home to go to, or some support system so they can continue medications. I'm sorry if I'm trembling, by the way, my office is freezing. There's only been two instances where patients were going to be. Homeless, and it depends on the level of homelessness, they would have one person had access to a shelter so they could keep their medications there, and they were going to go back every day. The other person truly had nothing, and the decision for that person in that particular case was to not provide treatment, because we were too afraid that treatment might be incomplete, which was a tough choice. Next slide. All right, let's talk about the pharmacy role in Hep C treatment in the correctional environment. So as Alex mentioned, we do want to be cognizant that as a federal agency, we fall under the Supremacy Clause, so we're not subject to specific state regulations. And I agree with them. I really hope that any individual state efforts are successful in getting pharmacists integrated in, because there's plenty of work to go around. In the bup, we have a strong clinical pharmacy program. We do anything from like more the administrative stuff, like putting together packets, submitting the request to direct patient care, like Alex and I have done, and this is for many these days, not just Hep C. And I think one of the how they're beneficial is that we can really laser focus on a specific thing like Hep C or HIV, or do a deep dive into something like disease state management, like insulin tweaking for diabetes, as opposed to your routine chronic care clinic for doctors, you got 515 minutes per patient that you may not have the space or time to do. VOP has five Clinical Pharmacy consultant programs. Hepatitis was the second. The others are, HIV, mental health, antimicrobial and substance use disorder. So hepatitis started in 2011 with six regional consult consultants, because we have six regions and one national program coordinator, and because Hep C treatment has just exploded, we now have about 18 to 20 regional consultants plus the coordinator. So we address the non formula requests, which I'll talk about next, and then we're also the subject matter experts are assigned sites and regions asking those questions about non adherence, weird side effects, reinfection behaviors and so on. It's always nice to have that ask so and so person to reach out to. The Consultant Program also led the first and only hepatitis C certificate training program. It's over five hours of continuing education or CE. We did it at our VOP pharmacy residential in 2018 and after that, we issued a challenge to the pharmacy field for treating Hep C, because treating one is better than none, and the number of hep C collaborative practice agreements, which we talked about at last week's webinar, increased from 14 to 39 in the first year, and we didn't even offer a prize. The prize is just curing your patients. And we do plan to continue developing and providing basic and advanced level CE so that our providers have all the resources they need to tackle any situation and eliminate Hep C at their sites.

Unknown Speaker  52:54  
Next slide. So

Commander Katrina Klang  52:57  
again, I mentioned before, we have a non formulary process. It's really more clinical review. Since we treat everyone, it's the same process for the entire agency. So the local site gets the labs, does the counseling, submits the request with all the documentation attached, and then the hepatitis clinical pharmacist consultant. It will never not be an easy thing to say, difficult thing to say, we review the request at the central office level, make sure everything all the labs are there. We choose the right treatment regimen, look at things like cirrhosis status, that kind of thing. And this also provides the opportunities for consultants to identify areas for education, like perhaps, and this happens all the time. We have a new provider who has become their site, Pepsi hero, and the consultant can help them streamline their process, maybe how to order the correct labs, how the dashboard can be used to so they don't have to do everything so manually. Perhaps you notice counseling notes are kind of sparse or maybe absent. So we provide a text string that helps guide their counseling session and provides consistent documentation. Next slide, and that ties in pretty well some general best practices that have proven successful in our agency, and I hope, have already been useful in your setting, or could be so the sites that do universal screening on intake tend to have the tightest safety net for screening, which is a vital step to achieve elimination. Alex already mentioned about the upcoming automated automated lab ordering, which I'm very, very thrilled about. It just takes up that manual part that's kind of prone to error, especially during the chaotic intake process. As just mentioned, having standard text strings or templates that helps guide your notes and counseling. It's not to make a cookie cutter, but it's to ensure that all appropriate aspects are explored. And he mentioned prioritizing by unit or area at Florence, my Warden told me to treat the supermax first, which did make sense. And then I went on from there, let's see. Sorry, I know we're getting close on time. And as much as I've talked about pharmacy, I strongly recommend utilizing all. Possible providers. I was happy to be the point person at Florence during my time, but I can never get below 15 to 30 patients at a time, because the door just kept revolving. So a team approach is best. I'm just going to wrap it up. We hope that your site has already experienced our successes and progress towards Hep C elimination. We hope that what we have shared can help someone, anyone with their eradication effort, and maybe learn from others, because I'm really glad we have some Dayton county people here too. And now open the floor to any questions.

Christopher Smith, NPA  55:34  
Hi everybody. This is Chris Smith again, if you will, go ahead and put any questions you have into the chat, we can then address them one at a time, and we'll get as many of them as we can. I'll give you guys a couple of minutes going into your questions and Lieutenant Commander, if you don't mind, while we're waiting on that, I thought I would add into your pre release commentary about treatment. Before I was here at Nic, I was a I worked my way from Case Manager to unit manager to CMC, and I just thought, I didn't put my input in. You know, when I was in, it was at the very start of first step back. We usually started planning release planning about a year, year and a half before an inmate river release. Now first step back is probably pushing a year and a half, two years. So that would be a timeframe if you guys wanted to get a unit team, and you obviously can't get into specifics about an inmates treatment, but if you guys could let this is a more applicable for the federal folks in the audience, if you guys could let the unit team know that a particular inmate has treatment and you'd like to start it and kind of work with them on the release planning that can not only be used to justify a longer placement at a halfway house, but as you guys may Know, halfway house beds have always been in a premium, so that may be the difference in that particular inmate getting a bed at a halfway house with a little more time or not. So what I would say is, if you don't have a relationship well with your unit team folks, now, maybe reaching out to your CMCS or unit managers may be able to start building that bridge where you guys can work more closely with uniting folks and be able to give them the limited information you can give them to help them on the release planning for those inmates,

Lieutenant Commander Alex Brorby  57:10  
absolutely, at any, any, any point possible that you can coordinate with custody folks to to be more effective is definitely a good idea. I know I've had patients who are like, I mean, I'm getting put in for a halfway house, but I have no idea when it might be. Being able to reach out to unit team just to get a better time frame has been helpful on multiple occasions. So thank you for that kind of custody input. Yes,

Christopher Smith, NPA  57:34  
sir. Haven't really got any questions.

Commander Katrina Klang  57:37  
So I'd like to go back to Dr, and I'm sorry if I mispronounced your name. Dr, called Donnie from New Jersey, Doc, I've been seeing your chat. I've been really enjoying it. You're talking about most hepatologists no longer recommending getting staging based on fib four, Apri, or anything else. Fib four. Yeah, so Apri was kind of a holdover from the days when we did use it to help prioritize. We had priority levels, which we don't have the time to dive into the nitty gritty of it, but that's when we were talking about prioritizing by highest morbidity, mortality risk. So the Apri helped us be like a surrogate to help prioritize those people. We still use it today, because if you have an Apri of two or greater, and there's always nuances, right? Is to get a cirrhosis evaluation. So, like an abdominal ultrasound to screen, because the Apri has like and I'm really bad at numbers, you know, sensitivity, specificity for advanced fibrosis and cirrhosis got it. So sometimes we have an Apri greater than two just because their AST is elevated. Their platelets are normal. Other labs are normal. And we could just say, repeat your lab, because maybe they're doing something. Ask about Tylenol use, over exercise, dehydration, drug use. And most of the time, those are normal the second time. But other times, we have platelets that are 80 or 30 or 110 which in itself should be a prompt to look for cirrhosis, but it doesn't always get done. So it's kind of just like another nice check that we do so we don't it doesn't affect treatment decisions. It helps treat the patient better. If that helps,

CAPT. Chad Garrett  59:21  
well, we are at time. So just like that, we've reached the end of today's session, and on behalf of the National Institute of Corrections, I want to extend a sincere thank you for your time, attention and engagement. We know your schedules are packed tighter than a medication card on morning rounds, and we appreciate making the space for this discussion as we wrap up, remember, clinical excellence is not a destination. It's a journey. It's the one best traveled with a solid team and a few good clinical pearls in your pocket. If today sparked any new ideas, challenges, any old ones even came up, well, that's great. That means we're. Doing our job, and if you're leaving with more questions than you came in, perfect that just means you're going to have to join us again next week, and next week we'll be having antimicrobial stewardship.

So if you would like to join us for our antimicrobial stewardship, you can use that Q code there and register. And with that, I want to thank you all very much. Go forth and be awesome. Thanks, everybody. Thanks, everyone you.

Transcribed by https://otter.ai